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Law Educator, Esq.
Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 117359
Experience:  JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
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Medicare lawyer My mom is in a SNF and after two weeks they

Customer Question

Medicare lawyer
My mom is in a SNF and after two weeks they terminated her Medicare coverage saying she did not progress in physical therapy and in their eyes is clinically stable. Her doctor that treated her during her hospital stay disagrees, and even think she deserves to be in a higher care facility as she has an unpredictable, delicate, and complex neuromuscular disorder requiring her to be on two external ventilator devices.
I read a lot of information online in Medicare pamphlets and the Elder Law website that state that Medicare covers patients that need this care to prevent deterioration and keep them stable. We have two instances where she was immediately hospitalized post a drop in care level to illustrate how delicate her condition is.
However the SNF says the internet information is incorrect and that I shouldn't believe everything I read. I don't, and I did a lot of research. Please tell me if this is true or not? I don't trust the SNF one bit, they are rude, and greedy, one of their employees told us that my mom wouldn't be able to stay long because they lose profit on her for having to rent her devices and they cost $1000 a month.
What is the criteria for continuing on Medicare at a SNF if in their eyes physical therapy has "plateaued"? The info I found said requiring a skilled level of care which she does need, but they claim it's custodial and it doesn't count even though it supposedly does. I'm very confused and really need some facts. The ombudsman sent a volunteer out and she was very biased and rude to me for no reason.
Does Medicare continue SNF coverage for a patient that's in a gray area, her case is not black and white so everything keeps getting overlooked. Is coverage based on physical therapy alone and is plateauing actually a legal excuse even if literature on the web suggests not?
Her doctor says she needs a respiratory therapist to survive and her day and night ventilator and someone to operate it. Supposedly the SNF said that there is some legalese that their RT's can not provide that care, so they have trained the nurses to do it, but because nurses are doing it and not RT that disqualifies her for Medicare. I find this very confusing how that can be a legal loophole?
Please help, I really appreciate any information you can provide. Thank you so very much!
Submitted: 1 year ago.
Category: Legal
Expert:  Law Educator, Esq. replied 1 year ago.
Thank you for your question. I look forward to working with you to provide you the information you are seeking for educational purposes only.
What you need to believe is you need a new SNF, because this one is unwilling or unable to provide her care. Your research is correct in that if her medical care provider orders that she needs such care then Medicare has to continue providing payment up to the maximum 100 days and then she would have to transfer over to Medicaid for longer term payment. You are correct though that the SNF care is covered as long as her doctor is requesting it and perhaps this is such a low quality or level care facility that they are not qualified to provide what she needs.
Customer: replied 1 year ago.
Hi,Thank you so much for your response. The SNF she is at now is a high level care facility, but because she's in a weird gray area because of her condition being so complex and not normal there is no facility that will take her or is set-up technically to help her. They have been meeting her needs decently but have used this as an excuse that Medicare should be terminated.I get a distinct sense it is only so they can profit, but they keep insisting I'm wrong and bullying me when I bring up the fact that her doctor's orders are what counts. The SNF insists that Medicare is only for short term care and if she was needing long term care that it wouldn't be provided by Medicare which doesn't make sense to me, but they keep arguing it and saying that the things her doctor is asking for are custodial care.Is there a Medicare law or anything I can state that might help them see that there is a legal aspect in her favor? If the ombudsman is unwilling to help and biased towards the SNF is there anyone else to report this to?If we're stuck keeping her here without any choices at the moment is there anything we can do to make them comply with what seems to be part of Medicare law? They keep saying their physician assessed her and he supersedes what her doctor orders, but her doctor is a specialist in his field and has treated her for a long time so I don't see how it's legal for a biased doctor without the necessary experience can make that call?It seems they are only providing the appeals process with documents that support their case and could even be fraudulent data as they are so eager to get her off of her coverage, is there any recourse there?Thank you so much for your help!
Expert:  Law Educator, Esq. replied 1 year ago.
Thank you for your reply.
Medicare is for short term care, they will pay a maximum of 100 days. So you need to contact medicare and work with them and stop dealing with the SNF. You also need to discuss with the doctor him ordering her to stay as well as you looking for a better location.
Here is the medicare page which explains Skilled Nursing benefits:
Customer: replied 1 year ago.
Thank you so much! I feel like the SNF are using anything they can find as an excuse and much of it isn't true.
That's what I was thinking too that short term care would be why it is only covered for 100 days. Thanks so much again for this info.
Customer: replied 1 year ago.
Oh sorry, just one last thing, is there any detailed guideline for what Medicare considers a skilled service vs custodial care? Everything I saw online said if it was administered or overseen by a nurse and was important to the patient staying stable that it counts as a skilled service that validates her coverage, but of course the SNF keeps saying that it's "custodial" and therefore not covered.
Expert:  Law Educator, Esq. replied 1 year ago.
Thank you for your reply.
I would suggest getting her moved to another SNF if they are not being cooperative, after all, why give them your business if they are acting this way.
Here is the definition of Skilled Care from the site:
"A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care. Nursing, physical therapy, occupational therapy, and speech therapy are considered skilled care by Medicare. In addition to providing direct care these professionals manage, observe, and evaluate your care. Any service that could be safely done by a non-medical person (or by yourself) without the supervision of a nurse isn't considered skilled care."
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